Tag Archives: ER Physicians

An accurate diagnosis via laboratory testing is critical for effectively treating persistent diarrhea lasting more than 2 weeks, as the often poorly recognized syndrome can be caused by different pathogens than acute diarrhea, according to a clinical review recently published in JAMA.

“I’d like to educate doctors about the importance of taking the history and assessing duration of illness,” Herbert L. DuPont, MD, Director of the Center for Infectious Diseases at The University of Texas Health Science Center at Houston School of Public Health, said in a press release. “For acute diarrhea, the lab has a minimal role, restricted to patients passing bloody stools. If a patient has had diarrhea for 2 weeks or more, the doctor should focus on the cause of the disease through laboratory testing, with an emphasis on parasites.”

DuPont performed a review of relevant literature published up to February 2016 to provide an overview of the epidemiology, etiology, diagnosis and management of persistent diarrhea in immunocompetent patients.

Common causes of persistent diarrhea

Although acute diarrhea is usually caused by viruses or toxins, persistent diarrhea is usually caused by bacteria or parasites, DuPont wrote.

Protozoa are the most common parasitic cause of persistent diarrhea, including Giardia, Cryptosporidium and Cyclospora, whereas Entamoeba histolytica, Cystoisospora belli, Dientamoeba fragilis, Strongyloides stercoralis and Microsporidia species are less common.

Clostridium difficile can cause recurrent diarrhea in patients receiving antibiotics in health care settings, and viral agents, such as norovirus, and helminths can also cause persistent diarrhea.

“Parasites are more common in the developing world. Consequently, persistent diarrhea is more common in these areas and in local populations or people traveling to these locations,” DuPont wrote. “Persistent diarrhea occurs in approximately 3% of international travelers to developing regions.” Parasitic infection is less common in industrialized regions, where foodborne and waterborne pathogens and C. difficileare more common causes, he added.

Duration of illness should be determined by health care providers when developing an evaluation plan, and the clinical assessment of patients with persistent diarrhea lasting more than 14 days should include a complete history, physical examination and diagnostic testing for infectious or noninfectious etiologies.

“The longer the duration of illness, the more likely it is that parasitic pathogens or noninfectious causes will eventually be identified,” DuPont wrote.

Previously, bacterial pathogens were identified using stool culture-based methods, and parasites are often identified using commercial enzyme immunoassay tests or microscopy. However, the recent advent of multiplex polymerase chain reaction (PCR) platforms enable simultaneous testing for a number of bacterial, viral and parasitic enteropathogens by identifying their DNA sequences.

“These new tests are easy to use, are capable of detecting a broad range of pathogens and represent a significant improvement over culture-based diagnostic approaches,” DuPont said in the press release. “The technology needs to be more widely available. Diagnosis is critical when treating persistent diarrhea.” However, false positive results are problematic, he wrote.

Treatment depends on diagnosis

After treating any dehydration with oral rehydration therapy, a laboratory test should be performed to determine the cause of persistent diarrhea to determine the appropriate treatment. However, a single 1,000 mg dose of empirical azithromycin is appropriate concurrent to the lab test for adults who have traveled to the developing world, as bacterial causes that lab tests cannot usually identify are common.

Although antimicrobial agents are recommended for a number of pathogens, the antibiotic choice should be optimized based on the pathogen’s susceptibility to prevent antimicrobial resistance.

In this episode Tex Kissoon, MD,a well-known physician from Canada, provided us with the insight into the global phenomenon of Sepsis. Sepsis affects more than 30 million lives per year yet it is almost unknown to the general public and is quite often misdiagnosed by medical professionals worldwide. The reasons of why that is with the “why” Sepsis is so deadly, and what you can do to increase Sepsis awareness– were discussed in 60 minutes. Dr. Kissoon was joined by Ray Schachter, a Sepsis survivor who now dedicates all of his available time raising awareness of Sepsis worldwide. Both guests are members of the Global Sepsis Alliance (GSA), which has established World Sepsis Day on September 13thevery year to raise awareness for Sepsis worldwide.

About Our Guests:

Dr. Niranjan “Tex” Kissoon, MD

Dr. Kissoon is the Past President of the World Federation of Pediatric Critical and Intensive Care Societies, Vice-President, Medical Affairs at BC Children’s Hospital and Professor, Pediatric and Surgery (Emergency Medicine) Department of Pediatrics at the University of British Columbia in Vancouver, BC as well as he holds the University of British Columbia BC Children’s Hospital (UBC BCCH) Endowed Chair in Acute and Critical Care for Global Child Health. Dr. Kissoon is the vice chair of the Global Sepsis Alliance, co-chair of World Sepsis Day and the International Pediatric Sepsis Initiative.). He has been involved in both advocacy and in promoting Canada-wide involvement in World Sepsis Day as part of a global initiative. He is also involved in promoting sepsis guidelines such that appropriate treatments are given even in areas where there are limited resources.

Dr. Kissoon was awarded a Distinguished Career Award by the American Academy of Pediatrics in 2013 for his contribution to the society and discipline as well as the prestigious Society of Critical Care Medicine’s (SCCM) Master of Critical Care Medicine award in 2015 in recognition of his tireless efforts and achievements as a prominent and distinguished leader of national and international stature. He was also awarded the BNS Walia PGIMER Golden Jubilee Oration 2015 Award for major contribution to Pediatrics in India from the Postgraduate Institute Medical Education and Research.

A Direct Quote From Our Guest and Sepsis Survivor; Ray Schachter:

“I miraculously survived acute Sepsis in 1996 due to extensive medical intervention and have experienced the immediate and long-term consequences on me and my family. I am the Chair of the Global Sepsis Alliance (GSA) Task Force whose goal is to have the UN mandate Sepsis as a World Health Day. Working with these very accomplished and committed people from GSA, many of whom are on the GSA Executive or Ambassadors, on this important project is a very special opportunity.”

About The Global Sepsis Alliance (GSA):
Sepsis is one of the most underestimated health risks. It affects more than 30 million people worldwide each year; for 6 to 8 million of them with a fatal outcome. Surviving patients often suffer for years from late complications.
This is all the more disturbing as sepsis incidence could be considerably reduced by some simple preventive measures such as vaccination and improved adherence to hygiene standards, early recognition and optimized treatment. The main danger of sepsis results from a lack of knowledge about it.
The founding members of the Global Sepsis Alliance (GSA) have recognized the need to elevate public, philanthropic and governmental awareness and understanding of sepsis and to accelerate collaboration among researchers, clinicians, associated working groups and those dedicated to supporting them. For this reason, they initiated the Global Sepsis Alliance in 2010. Together with supporting organizations from across the globe, we are united in one common goal:

The GSA wants to ensure that:

The incidence of sepsis decreases globally by implementation of strategies to prevent sepsis.

Sepsis survival increases for children (including neonates) and adults in all countries through the promotion and adoption of early recognition systems and standardized emergency treatment

Public and professional understanding and awareness of sepsis improve

Access to appropriate rehabilitation services improve for all patients worldwide

The measurement of the global burden of sepsis and the impact of sepsis control and management interventions improve significantly

The GSA Current priorities:

Acknowledgement of a resolution on sepsis including official designation of World Sepsis Day (WSD) as one of the World Health Days by the World Health Assembly.

Recognition of sepsis in the Global Burden of Disease Report

Increase of public awareness and implementation of quality improvement initiatives

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